MEDICAL AND DENTAL HISTORY (to be completed by patient)
Patient’s Full Name:_____________________________________ Date of Birth:___________________
Patient’s r Current r Previous Dentist(s):__________________________________________ Date of Last Dental Cleaning:______________
Patient’s r Current r Previous Physician(s):_______________________________________ Date of Last Physical Exam: _______________
A Please list your chief concerns for treatment: (# in order of priority):______________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ B What or who motivated you to seek treatment and what do you expect?___________________________________________________________________ C List all current medications including non-prescriptions:_______________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ D List all drug allergies:____________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ E List previous surgeries:___________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________
Please describe all “Yes” answer (use space at bottom of page if necessary)
1 High Blood Pressure _______________________________ r 29 Pain, popping, catching or locking in jaw joints ________ r 2 Chest pains or heart attack __________________________ r 30 Clench or grind your teeth _________________________ r 3 Stroke ___________________________________________ r 4 Rheumatic Fever/Mitral Valve Prolapse ________________ r 31 Wake up with sore jaws ____________________________ r 5 Any heart trouble, murmur or mitral valve prolapse, Angina ____ r 32 Frequent headaches (How many per week?____) ______ r 6 Prosthetic devices (heart, valve, hip, knee, etc.) ________ r 33 Dizziness, ringing or pain in ears ____________________ r 7 Any lung disease (T.B., emphysema, etc.) ______________ r 8 Asthma ___________________________________________ r 34 Tenderness or stiffness in the jaw, neck or back _______ r 9 Allergies or hay fever ______________________________ r 35 History of TMJ (jaw joint) problems or therapy _________ r 10 Sinus problems __________________________________ r 36 Have you ever received instructions regarding care of your teeth or gums __ r 11 Mouth breathing or excessive snoring _______________ r 37 Treated for or told you have gum disease _____________ r 12 Ulcers or stomach problems _______________________ r 13 Diabetes _________________________________________ r 38 Treated or consulted for orthodontic therapy __________ r 14 Hepatitis or liver disease (Jaundice) __________________ r 39 Had head, neck or jaw injuries ______________________ r 15 Kidney or bladder disease _________________________ r 40 Dental x-rays taken in the last year __________________ r 16 Thyroid trouble ___________________________________ r 41 Brush your teeth (how often) _______________________ r 17 Connective tissue disease _________________________ r 18 Arthritis or rheumatism ____________________________ r 42 Floss your teeth (how often) ________________________ r 19 Cancer (type, date) ________________________________ r 43 Bad breath or unpleasant tastes in your mouth ________ r 20 Serious illness not listed (list type, date) _____________ r 44 Bleeding gums ___________________________________ r 21 Subject to prolonged bleeding or bruise easily ________ r 22 Glaucoma _______________________________________ r 45 Sore or painful teeth _______________________________ r 23 Epilepsy, convulsions or seizures ___________________ r 46 Tooth sensitivity (hot, cold, sweets) _________________ r 24 Do you have HIV (AIDS)? __________________________ r 47 Fever blisters or mouth ulcers ______________________ r 25 Are you taking any Bisphosphonates (Fosamax, Aredia, Didronel) _ r 48 Tongue thrusting habit ____________________________ r 26 Pregnant or possibly pregnant (Nursing) ______________ r 27 Using birth control medications _____________________ r 49 Place a high priority on keeping your natural teeth _____ r 28 Use tobacco (types/how much) _____________________ r 50 Do you like your smile __________________________________ r Please expand on the above information (refer to letter or number) or add anything you feel is important: ________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ The above information is accurate and complete to the best of my knowledge: Date: mm/dd/yy
__________ Patient or Guardian’s Signature: __________________________ Doctor’s Signature: ______________________
s Initials: _________ ,_________; _________, _________; _________, _________; _________, _________;_________;
Party-Drogen, Bio-Drogen und antiretrovirale Therapie Der Konsum von „ Partydrogen “ gehört heute zum Lebensstil zweier Generationen, die mit den Formeln „Generation X „ und „Generation @ „ grob charakterisiert werden. Unter dem Begriff „Party-Drogen“ werden sehr unterschiedliche Substanzen zusammengefaßt. Der Begriff bezeichnet einen Konsumstil: Die Steigerung von Wohlempf
PRODUZIONI 2009 - 2010 CONCERTO PALAZZO APERTO ORCHESTRA GIOVANILE DI FIRENZE INTERVENTO MUSICALE ORCHESTRA PETIT ENSEMBLE DI SCANDICCI Musiche di A.Corelli, W.A.Mozart, E.Elgar In collaborazione con il Comune di Gambassi Terme Musiche di S.Nelson, K & H. Colledge PIEVE DI S.MARIA A CHIANNI - GAMBASSI TERME In collaborazione con Consiglio regionale della Toscana AU